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    Questionnaire
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<h2>AHA/ACSM Health/Fitness Facility Preparticipation </h2>
    <h2>Screening Questionnaire</h2>
    <p>Assess your health needs by marking all true statements. </p>
    <p>If you marked any of the 
        statements in this section, consult your physician or other appropriate 
        healthcare provider before engaging in exercise. You may need
       to use a facility with a medically qualified 
        staff.</p>
    <p><b>History</b></p>
    <p>You have had:</p>
    <p><input type = "checkbox"  /> A heart attack </p>
    <p><input type = "checkbox"  /> Heart surgery</p>
    <p><input type = "checkbox"  />  Cardiac catheterization</p>
    <p><input type = "checkbox"  />  Coronary angioplasty (PTCA)</p>
    <p><input type = "checkbox"  />  Pacemaker/implantable cardiac defibrillator/rhythm disturbance</p>
    <p><input type = "checkbox"  />  Heart valve disease</p>
    <p><input type = "checkbox"  />  Heart failure</p>
    <p><input type = "checkbox"  />  Heart transplantation</p>
    <p><input type = "checkbox"  />  Congenital heart disease</p>
    <p><input type = "checkbox"  />  Other health issues</p>
    <p><input type = "checkbox"  />  You have diabetes</p>
    <p><input type = "checkbox"  />  You have or asthma other lung disease.</p>
    <p><input type = "checkbox"  />  You have burning or cramping in your lower legs when walking short distances.</p>
    <p><input type = "checkbox"  />  You have musculoskeletal problems that limit your physical activity.</p>
    <p><input type = "checkbox"  />  You have concerns about the safety of exercise.</p>
    <p><input type = "checkbox"  />  You take prescription medication(s).</p>
    <p><input type = "checkbox"  />  You are pregnant.</p>
    <p><b>Symptoms</b></p>
    <p><input type = "checkbox"  />  You experience chest discomfort with exertion.</p>
    <p><input type = "checkbox"  />  You experience unreasonable breathlessness.</p>
    <p><input type = "checkbox"  />  You experience dizziness, fainting, blackouts.</p>
    <p><input type = "checkbox"  />  You take heart medications.</p> 
    <p>If you marked two or more of the statements in this section, you should consult your physician or other 
        appropriate healthcare provider before engaging in exercise. You might benefit 
        by using a facility with a professionally qualified exercise staff to guide your 
        exercise program.</p>
   <p><b>Cardiovascular risk factors</b></p>
    <p><input type = "checkbox"  />  You are a man older than 45 years.</p>
    <p><input type = "checkbox"  />  You are a woman older than 55 years, you have had a hysterectomy, or you are postmenopausal.</p>
    <p><input type = "checkbox"  />  You smoke, or quite within the previous 6 mo.</p>
    <p><input type = "checkbox"  />  Your BP is greater than 140/90.</p>
    <p><input type = "checkbox"  />  You don't know your BP.</p>
    <p><input type = "checkbox"  />  You take BP medication.</p>
    <p><input type = "checkbox"  />  Your blood cholesterol level is > 200 mg/dL.</p>
    <p><input type = "checkbox"  />  You don't know your cholesterol level.</p>
    <p><input type = "checkbox"  />  You have a close blood relative who had a heart attack before age 55 (father or brother) or age 65 (mother or sister).</p>
    <p><input type = "checkbox"  />  You are physically inactive (i.e., you get less than 30 min. of physical activity on at least 3 days per week).</p>
    <p><input type = "checkbox"  />  You are more than 20 pounds overweight.</p>
    <p style = " text-align:center">
    <% Html.BeginForm("Questionnaire", "PARQController", FormMethod.Post); %>
    <input type="submit" name="submitButton" value="YES to any of the risk factors" />
    <input type="submit" name="submitButton" value="None of the above are true" />
    <% Html.EndForm(); %>
    </p>
    </form>
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